Do not write your name on this form

Do Not Write your Name on this Form
This section to be filled out by lab personnel Subject ID #
This worksheet will assist you in informing us about your child’s medication history. Please be as honest and accurate as possible.
Please fill out this form to the best of your ability and bring it with you to your appointment.
Please provide the following information about all of the prescription medication your child is CURRENTY taking. If you need more
room, please use the back of the page.
Name of Medication
Dose (amount
# of times a day
What is the
How long has he been on this
listed on bottle)
medication for?
medication? (months)

Now we would like to know about medications your child may have been prescribed in the past, but NO LONGER takes (if he or she
still takes the medication, provide that information in the space above. Use the space below, however, if he or she previously took a
different medication for the same condition as listed above). We will provide a list of medications that your child may have taken, and
the usual reason such medication is prescribed. Because most medications with a similar way of working may have multiple brand
names and generic names, we can not list all of them. We have tried to group them by category. If your child has taken a medicine in
this category, please provide the name of the specific medication. If you are having trouble remembering the names of some
medications, please bring as much information with you to your visit, we can provide you with a list of possible medication names to
help your remember. We do not need to know about temporary treatments such as antibiotics.
Prescription medication your child has taken in the PAST.
Type of Medication
Specific Name of
Age first
Length of time
Dose Results
taken (months)
asthma maintenance) Bronchodilator (inhaler for acute asthma attacks) Prescription decongestant (prolonged allergies or cold symptoms) Epilepsy treatment treatment for migraine headaches Treatment for ADHD (methylphenidate, Ritalin, Adderall, or other) Antidepressants (for depression or chronic anxiety) (Prozac, Zoloft, Paxil, imiprimine, anafranil, others) Benzodiazepines (for anxiety) (Valium, Xanax, Ativan, diazepam, and others) Type of Medication
Specific Name of
Age first
Length of time
taken (months)
carbamazapine, lithium, depakote and others) Antipsychotic medication (for bipolar or other
conditions) (Risperdal,
Clozapine, and others)
List any other medications

In preparation for your visit to the laboratory, please refrain from giving your child any over-the-counter medication for colds
or congestion. These include, Day-quil, Ny-quil, Sudaphed (either the formula available on the shelf or behind the
pharmacist’s counter) or any generic versions of these drugs. If you have any questions about other medications your child is
taking please feel free to call us to check. Some of these medications may affect how the body works and interfere with the
type of measurement that we can take. Please also limit your child’s intake of caffeine (e.g. Soda) immediately before your
visit. Thank you.


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